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1071 Digital Single-Operator Pancreatoscopy for Evaluation of Intraductal Papillary Mucinous Neoplasm
Abstracts
1067 Cholangioscopy in the Management of a NearObstructing Post-Transplant Biliary Stricture Zachary L. Smith*, Daniel Mullady Washington University School of Medicine, St. Louis, MO A 53-year-old female had undergone liver transplantation 10 months previously for alcohol related cirrhosis. During transplant surgery, a large size mismatch between the donor and the recipient bile ducts was noted. Because of this, a separate orifice in the recipient bile duct was created to facilitate the creation of the biliary anastomosis. Her postoperative course was unremarkable until she was incidentally noted to have worsening serum liver chemistry and a post-transplant biliary anastomotic stricture was suspected. The patient was referred for ERCP for evaluation and attempts at therapy. After biliary cannulation a markedly dilated recipient bile duct was noted. Despite numerous attempts, the donor ductal system was not able to be opacified. A 0.025” hydrophilic guidewire was not able to be advanced into the donor ductal system. Digital cholangioscopy was utilized and a small orifice presumed to be the biliary anastomosis was identified. The wire was passed through the anastomosis on direct visualization. Following this, full of pacification of the donor doctoral system was performed. The stricture was then dilated with the 6 mm dilating balloon and a 10 French biliary stent was placed. Four weeks later serum liver chemistry has normalized in the patient was doing well.
1068 Hemostatic Powder: A New Ally for the Management of Post-Sphincterotomy Bleeding Felipe I. Baracat, Vitor O. Brunaldi*, Diogo T. de Moura, Sergio E. Matuguma, Renato Baracat, Eduardo G. de Moura Gastroenterology Department - Endoscopy Unit, Faculty of Medicine of University os São Paulo, São Paulo, São Paulo, Brazil Endoscopic retrograde cholangiopancreatography (ERCP) is an important ally for the management of choledocolithiasis as it presents low morbid-mortality rates and presents great outcomes. Despite most favorable data, adverse events such as perforation, pancreatitis and bleeding are not rare. Amongst them, post-sphincterotomy bleeding is the most challenging for endoscopists, since the major therapeutic strategy is endoscopic hemostatis. Uncontrolled bleeding demands emergency surgery and presents high mortality rate. New hemostatic technologies are needed in order to facilitate endoscopic treatment, which is very difficult on sided-view endoscope and while active bleeding blurs the lens. We exhibit a video in which Hemostatic Powder is used to control post-sphincterotomy bleeding in a 69years-old male patient. He was referred to our tertiary center with the diagnosis of choledocolithiasis. ERCP confirmed that diagnosis and sphincterotomy followed by calculi extraction were performed. Two days later, the patient presented melena and new duodenoscopy identified oozing bleeding from sphincterotomy site. Epinephrine injection followed by Hemostatic Powder application were performed and successfully achieved hemostasis. Patient did not experience pancreatitis, rebleeding or transient biliary obstruction, and was discharged home two days after this procedure. Our initial experiences with the Hemostatic Powder are exciting especially when bleeding is severe and located at an unfavorable clipping site. Based on our experience, pariampullary bleeding is not contraindication for the use of the powder. Comparative studies are still needed to correctly assess its hemostatic capability.
1069 New Methods of Teaching the Axis in Ercp: Can I Write My Name? Rosario Landi1, Ivo Boskoski*1,2, Vincenzo Bove1, Andrea Tringali1, Pietro Familiari1, Vincenzo Perri1, Guido Costamagna1,3 1 Digestive Endoscopy Unit, Catholic University of Rome, Roma, Italy; 2 Service de Chirurgie Digestive & Endocrinienne, IHU Strasbourg, Strasbourg, France; 3USIAS Strasbourg University, Strasbourg, France Endoscopic retrograde cholangio-pancreatography (ERCP) is the most difficult endoscopic procedure and extensive training is needed to gain competence. Teaching to gain the correct axis is of paramount importance in ERCP. The purpose of this video is to show to young fellows aiming to learn ERCP that any direction and any axis can be reached with the tip of an accessory trough the duodenoscope. For this purpose we used the Boskoski-Costamagna ERCP trainer (Cook Medical Winston-Salem) with a piece of paper placed in the site of the papilla and a specially designed pencil. The word “ERCP” was written on the paper by coordinated and combined movement of the duodenoscope, the elevator and the accessory.
www.giejournal.org
1070 Eus Guided Gastrostomy and Subsequent ERCP: Treatment of Jaundice in a Patient With Gastric Bypass and Peritoneal Carcinomatosis Joseph B. Henderson*1, Tariq Nazir2, Arvind Kumar1, John Poulos1 1 Fayetteville Gastroenterology Associates, Fayetteville, NC; 2Oncology, Cape Fear Valley Hospital, Fayetteville, NC 72 yo white, active female with hx of gastric bypass developed jaundice 3 months after being diagnosed with peritoneal carcinomatosis upon laparoscopic cholecystectomy. The patient had subsequent PTC, with the external bag affecting her quality of life. ERCP via enteroscopy approach failed. The patient was not a candidate for intraoperative gastrostomy of the remnant secondary to peritoneal carcinomatosis. The gastric remnant had a normal appearance upon endoscopic evaluation. A 19gauge access needle was used to puncture the gastric walls and a guide wire was advanced and curled into the remnant stomach. This was followed by a needle knife, which was used to dilate and puncture the track. The catheter was advanced over the guidewire and contrast was injected, outlining the gastric remnant. We exchanged for a 6mm dilating balloon for track dilatation, followed by placement of a 15mm x 10mm fully covered biflanged stent. The distal and proximal ends of the stent were deployed. The guidewire was left in place, and over the guidewire, a 1215mm esophageal-dilating balloon was used to dilate the stent. The opposite wall, the gastric remnant was visualized. We then exchanged the linear echoendoscope for the side viewing scope. The scope was advanced carefully across the stent, to the level of the papilla. The CBD was cannulated, with advancement of the guidewire. Cholangiogram showed a long distal biliary stricture. Sphincterotomy to the horizontal fold was performed. A 10x60mm fully covered biliary stent was placed across the stricture, with excellent flow of bile through the stent. Upon scope withdraw, excellent positioning of the gastric stent was seen. Upon stent removal 4 weeks later, there was no evidence of perforation. EUS guided gastrostomy with subsequent ERCP was well tolerated in this patient and may be a therapeutic option when other options are not feasible.
1071 Digital Single-Operator Pancreatoscopy for Evaluation of Intraductal Papillary Mucinous Neoplasm David Albers*1, Dani Dakkak1, William Sterlacci2, Michael Vieth2, Brigitte Schumacher1 1 Gastroenterology, Elisabeth-Krankenhaus, Essen, Germany; 2Pathology, Klinikum Bayreuth, Bayreuth, Germany Whereas main-duct-IPMN and mixed-type-IPMN are associated almost certainly with malignancy and usually leaded to surgery, branch-duct-IPMNs biologically behave more indolent. Prediction of malignancy is a crucial point to distinguish between surgical therapy and conservative management in this heterogenous group of cystic neoplasia. We report on a 58-year old female with pancreatic carcinoma in her family history presented with two cystic lesions for diagnostic work-up. The diagnosis of a branch-duct-IPMN was established by EUS, but a main-duct involvement could not be excluded. Subsequently digital single-operator pancreatoscopy was performed and involvement of the main pancreatic duct was endoscopically and histologically verified.
1072 One-Step Endoscopic Ultrasound Directed GastroGastrostomy ERCP (EDGE) Ming-ming Xu*, Carlos Carames, Aleksey Novikov, Monica Saumoy, Cheguevera Afaneh, Michel Kahaleh, Reem Z. Sharaiha Weill Cornell Medical Center, New York, NY A 32 year old woman with history of obesity who underwent roux-en-y gastric bypass in 2005 presents with acute cholecystitis. She undergoes laparoscopic cholecystectomy, this was converted to open cholecystectomy due to significant inflammation and adhesions. On post-operative day 2 she is noted to have 300cc of bilious output from the Jackson-Pratt (JP) drain concerning for bile leak. GI is consulted for ERCP and management of bile leak. Laparoscopy-assisted ERCP was felt to be high risk and difficult due to her recent open cholecystectomy with significant adhesions and inflammation. Enteroscopy-assisted ERCP was felt to have low likelihood of success due to a roux-limb length of >150cm. Decision was made to pursue EUS directed gastro-gastrostomy ERCP in one step (EDGE). EDGE involves the creation of a gastro-gastrostomy fistula to gain access into the bypassed stomach. Conventional ERCP is then performed through gastro-gastrostomy (G-G) fistula after fistula maturation, usually after 4-6 weeks. On post-procedure day 1 the JP drain output was no longer bilious and had decreased in volume. On post-procedure day 2 the patient was discharged home. Patient returned for outpatient ERCP with stent removal 8 weeks later with resolution of bile leak on cholangiogram. The gastro-gastric fistula tract was closed with endoscopic suturing. Successful management of bile leak via EDGE procedure is feasible in one step.
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB133
1067 Cholangioscopy in the Management of a NearObstructing Post-Transplant Biliary Stricture Zachary L. Smith*, Daniel Mullady Washington University School of Medicine, St. Louis, MO A 53-year-old female had undergone liver transplantation 10 months previously for alcohol related cirrhosis. During transplant surgery, a large size mismatch between the donor and the recipient bile ducts was noted. Because of this, a separate orifice in the recipient bile duct was created to facilitate the creation of the biliary anastomosis. Her postoperative course was unremarkable until she was incidentally noted to have worsening serum liver chemistry and a post-transplant biliary anastomotic stricture was suspected. The patient was referred for ERCP for evaluation and attempts at therapy. After biliary cannulation a markedly dilated recipient bile duct was noted. Despite numerous attempts, the donor ductal system was not able to be opacified. A 0.025” hydrophilic guidewire was not able to be advanced into the donor ductal system. Digital cholangioscopy was utilized and a small orifice presumed to be the biliary anastomosis was identified. The wire was passed through the anastomosis on direct visualization. Following this, full of pacification of the donor doctoral system was performed. The stricture was then dilated with the 6 mm dilating balloon and a 10 French biliary stent was placed. Four weeks later serum liver chemistry has normalized in the patient was doing well.
1068 Hemostatic Powder: A New Ally for the Management of Post-Sphincterotomy Bleeding Felipe I. Baracat, Vitor O. Brunaldi*, Diogo T. de Moura, Sergio E. Matuguma, Renato Baracat, Eduardo G. de Moura Gastroenterology Department - Endoscopy Unit, Faculty of Medicine of University os São Paulo, São Paulo, São Paulo, Brazil Endoscopic retrograde cholangiopancreatography (ERCP) is an important ally for the management of choledocolithiasis as it presents low morbid-mortality rates and presents great outcomes. Despite most favorable data, adverse events such as perforation, pancreatitis and bleeding are not rare. Amongst them, post-sphincterotomy bleeding is the most challenging for endoscopists, since the major therapeutic strategy is endoscopic hemostatis. Uncontrolled bleeding demands emergency surgery and presents high mortality rate. New hemostatic technologies are needed in order to facilitate endoscopic treatment, which is very difficult on sided-view endoscope and while active bleeding blurs the lens. We exhibit a video in which Hemostatic Powder is used to control post-sphincterotomy bleeding in a 69years-old male patient. He was referred to our tertiary center with the diagnosis of choledocolithiasis. ERCP confirmed that diagnosis and sphincterotomy followed by calculi extraction were performed. Two days later, the patient presented melena and new duodenoscopy identified oozing bleeding from sphincterotomy site. Epinephrine injection followed by Hemostatic Powder application were performed and successfully achieved hemostasis. Patient did not experience pancreatitis, rebleeding or transient biliary obstruction, and was discharged home two days after this procedure. Our initial experiences with the Hemostatic Powder are exciting especially when bleeding is severe and located at an unfavorable clipping site. Based on our experience, pariampullary bleeding is not contraindication for the use of the powder. Comparative studies are still needed to correctly assess its hemostatic capability.
1069 New Methods of Teaching the Axis in Ercp: Can I Write My Name? Rosario Landi1, Ivo Boskoski*1,2, Vincenzo Bove1, Andrea Tringali1, Pietro Familiari1, Vincenzo Perri1, Guido Costamagna1,3 1 Digestive Endoscopy Unit, Catholic University of Rome, Roma, Italy; 2 Service de Chirurgie Digestive & Endocrinienne, IHU Strasbourg, Strasbourg, France; 3USIAS Strasbourg University, Strasbourg, France Endoscopic retrograde cholangio-pancreatography (ERCP) is the most difficult endoscopic procedure and extensive training is needed to gain competence. Teaching to gain the correct axis is of paramount importance in ERCP. The purpose of this video is to show to young fellows aiming to learn ERCP that any direction and any axis can be reached with the tip of an accessory trough the duodenoscope. For this purpose we used the Boskoski-Costamagna ERCP trainer (Cook Medical Winston-Salem) with a piece of paper placed in the site of the papilla and a specially designed pencil. The word “ERCP” was written on the paper by coordinated and combined movement of the duodenoscope, the elevator and the accessory.
www.giejournal.org
1070 Eus Guided Gastrostomy and Subsequent ERCP: Treatment of Jaundice in a Patient With Gastric Bypass and Peritoneal Carcinomatosis Joseph B. Henderson*1, Tariq Nazir2, Arvind Kumar1, John Poulos1 1 Fayetteville Gastroenterology Associates, Fayetteville, NC; 2Oncology, Cape Fear Valley Hospital, Fayetteville, NC 72 yo white, active female with hx of gastric bypass developed jaundice 3 months after being diagnosed with peritoneal carcinomatosis upon laparoscopic cholecystectomy. The patient had subsequent PTC, with the external bag affecting her quality of life. ERCP via enteroscopy approach failed. The patient was not a candidate for intraoperative gastrostomy of the remnant secondary to peritoneal carcinomatosis. The gastric remnant had a normal appearance upon endoscopic evaluation. A 19gauge access needle was used to puncture the gastric walls and a guide wire was advanced and curled into the remnant stomach. This was followed by a needle knife, which was used to dilate and puncture the track. The catheter was advanced over the guidewire and contrast was injected, outlining the gastric remnant. We exchanged for a 6mm dilating balloon for track dilatation, followed by placement of a 15mm x 10mm fully covered biflanged stent. The distal and proximal ends of the stent were deployed. The guidewire was left in place, and over the guidewire, a 1215mm esophageal-dilating balloon was used to dilate the stent. The opposite wall, the gastric remnant was visualized. We then exchanged the linear echoendoscope for the side viewing scope. The scope was advanced carefully across the stent, to the level of the papilla. The CBD was cannulated, with advancement of the guidewire. Cholangiogram showed a long distal biliary stricture. Sphincterotomy to the horizontal fold was performed. A 10x60mm fully covered biliary stent was placed across the stricture, with excellent flow of bile through the stent. Upon scope withdraw, excellent positioning of the gastric stent was seen. Upon stent removal 4 weeks later, there was no evidence of perforation. EUS guided gastrostomy with subsequent ERCP was well tolerated in this patient and may be a therapeutic option when other options are not feasible.
1071 Digital Single-Operator Pancreatoscopy for Evaluation of Intraductal Papillary Mucinous Neoplasm David Albers*1, Dani Dakkak1, William Sterlacci2, Michael Vieth2, Brigitte Schumacher1 1 Gastroenterology, Elisabeth-Krankenhaus, Essen, Germany; 2Pathology, Klinikum Bayreuth, Bayreuth, Germany Whereas main-duct-IPMN and mixed-type-IPMN are associated almost certainly with malignancy and usually leaded to surgery, branch-duct-IPMNs biologically behave more indolent. Prediction of malignancy is a crucial point to distinguish between surgical therapy and conservative management in this heterogenous group of cystic neoplasia. We report on a 58-year old female with pancreatic carcinoma in her family history presented with two cystic lesions for diagnostic work-up. The diagnosis of a branch-duct-IPMN was established by EUS, but a main-duct involvement could not be excluded. Subsequently digital single-operator pancreatoscopy was performed and involvement of the main pancreatic duct was endoscopically and histologically verified.
1072 One-Step Endoscopic Ultrasound Directed GastroGastrostomy ERCP (EDGE) Ming-ming Xu*, Carlos Carames, Aleksey Novikov, Monica Saumoy, Cheguevera Afaneh, Michel Kahaleh, Reem Z. Sharaiha Weill Cornell Medical Center, New York, NY A 32 year old woman with history of obesity who underwent roux-en-y gastric bypass in 2005 presents with acute cholecystitis. She undergoes laparoscopic cholecystectomy, this was converted to open cholecystectomy due to significant inflammation and adhesions. On post-operative day 2 she is noted to have 300cc of bilious output from the Jackson-Pratt (JP) drain concerning for bile leak. GI is consulted for ERCP and management of bile leak. Laparoscopy-assisted ERCP was felt to be high risk and difficult due to her recent open cholecystectomy with significant adhesions and inflammation. Enteroscopy-assisted ERCP was felt to have low likelihood of success due to a roux-limb length of >150cm. Decision was made to pursue EUS directed gastro-gastrostomy ERCP in one step (EDGE). EDGE involves the creation of a gastro-gastrostomy fistula to gain access into the bypassed stomach. Conventional ERCP is then performed through gastro-gastrostomy (G-G) fistula after fistula maturation, usually after 4-6 weeks. On post-procedure day 1 the JP drain output was no longer bilious and had decreased in volume. On post-procedure day 2 the patient was discharged home. Patient returned for outpatient ERCP with stent removal 8 weeks later with resolution of bile leak on cholangiogram. The gastro-gastric fistula tract was closed with endoscopic suturing. Successful management of bile leak via EDGE procedure is feasible in one step.
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB133